Out-of-Network vs. In-Network Providers

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Why you may want to work with Practical Recovery, an out-of-network provider, rather than with an in-network provider

If price is your primary consideration, then using an in-network addiction treatment provider is an easy choice.

If you have flexibility on this issue there are other issues to consider. Of course, you may be fortunate and not encounter any of the problems listed below. However, we regularly hear from our clients about the problems they have encountered “going in network.”

1) Outpatient in-network providers can be hard to find. One of the ways insurance companies save money is to put roadblocks in the way of you accessing. Although they will emphasize how large and qualified their networks are, have you tried to find an in-network provider who can see you anytime soon? Who even returns your phone call? Most of these networks are simply too small to service the demand. The insurer is happy for you to go out-of-network. It typically costs them less money.

2) The more qualified providers tend to be out-of-network. Imagine yourself as a provider. The insurer makes you get pre-authorization for a limited number of sessions, fights you about getting additional ones, and often does not pay your claim unless you fight over that issue also. The upshot is that you need to focus more on the insurance company than your client.

Consequently outpatient in-network providers tend to be newer in practice (aiming to break free from managed care eventually) or providers who do not compete as well on the open market for services. There are many exceptions to this statement in areas highly saturated with providers, but even there providers are selective about the networks they belong to. The insurance company you (the client) signed up with because it had the lower premium is the one that typically pays providers less, and consequently has a lower quality network of providers.

3) In-network residential addiction treatment is oriented around groups provided by drug and alcohol counselors. Click here for an article on the importance of individual sessions. These facilities need to operate in this manner because of the low rate of reimbursement, most of which is covering the facility, the food and basic medical requirements. Quality treatment is an afterthought.

4) Most in-network providers, residential (inpatient) and outpatient, are 12-step oriented. If 12-step oriented treatment is what you are looking for, that is where to find it.

Given these probabilities, what should you do?

1) If without excessive effort you can find an in-network provider you are pleased with, consider yourself lucky!

2) If you need residential treatment, and can get coverage for a few days or weeks at an in-network facility (don’t worry, if you don’t really need it they are not going to pay for it), it is worth considering. Particularly if you need detox, a short stay in network may allow you time to clear your head and get prepared to participate in genuinely meaningful therapeutic work once you discharge. Of course, there are some excellent providers in in-network facilities. But how much time will you get with them?

3) If you can afford out of network residential treatment, it may be worthwhile, but be careful. The cost for a good facility will be approximately 60K per month, with wide variations in price. How many individual sessions will you participate in? Who will provide them? What are the facility requirements? Are you paying more for amenities than treatment?

4) Even if you can afford out-of-network residential treatment, for selected individuals Practical Recovery’s Individual Intensive Outpatient Program (IIOP) is much more flexible, much less expensive, and typically much more intensive. What might take 30 days in residential treatment could be accomplished in an intensive IIOP in half the time, and one quarter the cost.

5) Consider the low cost groups and workshops that Practical Recovery makes available. In them you will get the full benefit of the self-empowering approach, while keeping costs low. There are also over 30 free SMART Recovery meetings each week in San Diego County. Combining these options, possibly with an individual session on occasion, could allow you to create an effective plan for yourself.

6) In addition to considering cost per session or cost per day, consider total cost. We have talked to many families who have spent small fortunes on treatment. We believe that had they spent more in the beginning they might have saved themselves years of drama and much money over the long run.

7) Keep in mind that poor treatment may be inadequate but it might also be harmful. If your motivation, or your loved one’s motivation, is not very strong, poor treatment could send you back to drinking/using. Upon discharge are you so upset with the facility that you go out to drink/use just to spite them? Perhaps you have read stories about how people go back to treatment again and again and again? No one can guarantee that slips and relapses will not occur. However, it is striking how often clients who relapse do not want to return to their last facility. They keep hoping someplace else will be better. If the facility had provided truly individualized care, the client would be eager to return to the professionals with whom relationships had already been established. At Practical Recovery you will receive truly individualized care, provided by highly knowledgeable and experienced doctoral level providers. We believe there is no finer treatment available anywhere.